Financial, Legal & Medical Coverage

When you or someone you love is diagnosed with cancer, it can be overwhelming at times. Not only are you concerned about your physical & emotional well being, but there are also many questions about your medical insurance coverage and what other services are available to help.

The following information is to provide basic information about what is available to patients & caregivers. Not everyone will need to use all the services listed or will be qualified to receive them. Your employer, hospital or cancer center will also be able to help answer some of your questions and concerns.

Understanding Your Medical Insurance


Medicare

A type of health insurance available to those who are age 65 or older. Medicare Part A covers inpatient expenses, skilled nursing homes, and some home health care services. Medicare Part B covers outpatient health care expenses including physician fees, equipment, and some supplies. You will need to pay 20% of costs after your yearly deductible is met for Part B. It is a good idea to have a supplemental health insurance that can pick up some of the co- payments.

Medicare Coverage for Inpatient Hospital Stays - Medicare pays all covered costs except the $1,068 yearly deductible during day 1 – 60 of an inpatient hospital stay. Medicare will pay $267 per day for days 61- 90 and $534 (life time reserve days) for day 91- 150 for a hospital stay. The patient will pay all costs for 150 -365 days of an inpatient hospital stay. * based on 2009 rates.

Medicare Coverage for Hospice Programs – Hospice is a program of care and support for people who are terminally ill. Hospice is generally given in your home. It includes drugs, physical care, counseling both emotional & spiritual needs, equipment, & supplies. It focuses on comfort to live out the time that they have remaining to the fullest extent not on curing an illness.

Medicare Part A will pay for hospice services when your Doctor & the Hospice Medical Director certify that you have six months or less to live. You will sign a statement choosing hospice to treat your illness. Medicare will no longer cover treatment intended to cure your illness.

  • You have a right to stop Hospice Care at any time & receive the same Medicare coverage that you had before you choose Hospice.
  • With Hospice, you will pay no more than $5 for each prescription drug or products for pain relief or symptom control
  • Medicare will also pay for a short term inpatient hospital or skilled nursing home stay if you or your caregiver need a break. This is called Respite Care. You will pay 5% of the Medicare approved amount for inpatient respite care.
  • If you live longer than 6 months, you can still receive Hospice Care as long as the Hospice Medical Director recertifies that you are terminally ill.

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Medicare Prescription Drug coverage

Medicare Prescription Coverage is an optional insurance that covers both brand name – generic prescription drugs at participating pharmacies in your area. It helps people with very high drug costs or unexpected drug bills in the future. Everyone with Medicare is eligible for coverage. You need to sign up for prescription drug coverage or have a plan that offers it. You will pay a monthly premium, which varies plan to plan, and a yearly deductible. You will also pay for part of your prescription costs called co- payments. The cost varies depending on the plan you choose.

  • Medicare beneficiaries are eligible for extra help with prescription drug coverage if you have limited income & resources. You qualify, you need to contact your local Social Security Office to see if you are eligible.

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Social Security Disability

Esophageal Cancer and Social Security Disability Benefits

If you have been diagnosed with esophageal cancer you may be eligible to receive Social Security Disability benefits. Disability benefits can help cover your day-to-day expenses while you are unable to work.

This article provides you with a general overview of the two main disability benefit programs and prepares you to submit an application with for esophageal cancer.

SSDI & SSI

Social Security Disability benefits are governed and distributed by the Social Security Administration (SSA). These benefits include Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI).

SSDI is intended to provide financial assistance to disabled workers and their eligible family members. Eligibility for SSDI is contingent upon the amount of ‘work credits’ accrued during the course of the applicant’s career. Work credits are a measure of an applicant’s past income and Social Security tax contributions. SSDI is best suited for individuals who have worked and paid Social Security taxes for a significant amount of time. Learn more about SSDI eligibility, here: http://www.disability-benefits-help.org/ssdi/qualify-for-ssdi.

SSI is intended to provide financial support to disabled or sick individuals who earn very little income. Eligibility for SSI is based solely on a person’s income and the resources that they own. If you exceed the SSA’s financial limits, you are not eligible for SSI benefits. Learn more about SSI eligibility, here: http://www.socialsecurity.gov/ssi/text-eligibility-ussi.htm.

Medical Eligibility

In addition to meeting the SSDI or SSI technical requirements, applicants must meet certain medical standards. You can find these standards in the SSA’s Blue Book—their guide of disabilities and conditions that qualify a person to receive disability benefits.

Esophageal cancer is evaluated under Blue Book listing, 13.16A. This listing states that applicants who have been diagnosed with a carcinoma or sarcoma of the esophagus are eligible to receive disability.

Application Process

If, after reviewing the technical and medical requirements for disability benefits, you feel that you are a qualified candidate, you should begin to prepare for the application process. To qualify, you need to collect a variety of records to support your claim. This should include medical records, financial records, and employment records. For a complete list of items, visit the Adult Disability Checklist.

To begin the application process, you can submit the necessary paperwork online or in person at a near-by Social Security office. To apply in-person, you must call the SSA to schedule an appointment ahead of time. When filling out the application forms, be sure to provide clear and detailed answers. Any missing or inconsistent information could potentially harm the outcome of your claim.

Compassionate Allowance

Typically, it can take anywhere from several months to a year to receive a decision on an initial disability claim. Fortunately, applicants who have esophageal cancer do not have to wait that long because esophageal cancer is included among the SSA’s Compassionate Allowance Listings. Essentially, the Compassionate Allowance program allows individuals with severely disabling conditions to receive benefits in as little as ten days.

If you are approved for disability benefits, you should receive a letter in the weeks following your application submission. The letter will outline the details of your benefits and the payment schedule. If your application is denied, you will receive a letter explaining the reason for your denial and explaining how to file an appeal.

If your application is denied, do not panic. You should file an appeal as soon as possible. Because esophageal cancer is a Compassionate Allowance condition, your claim is expedited throughout the appeals process as well.

Learn more about applying for disability benefits with esophageal cancer, here: http://www.disability-benefits-help.org/compassionate-allowances/esophageal-cancer-and-social-security-disability.

Preceding article by Molly Clarke, Writer for Social Security Disability Help

Family members may qualify for benefits based on your work:

  • Your spouse, 62 or older
  • Your spouse, at any age, if they are caring for your children who are younger than 16, are disabled, or under the age of 19 who are a full time student.

Skilled Nursing Facility – About half of all nursing home residents pay for nursing home costs out of their own savings. After these savings & other resources are spent, many people who stay in a nursing home for a long period of time become eligible for Medicaid. Medicare pays only for medically necessary skilled services. After a 3 day hospital stay, Medicare pays day 1 -20 of a skilled nursing facility at 100%, day 21- 100 are paid 80% as long as you are receiving skilled services. Medicare does not pay for custodial care such as dressing, bathing, and toileting.

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Long Term Care Insurance

Long Term Care is a private policy that can help pay for the cost of a Skilled Nursing Facility.

Program All Inclusive Care for the Elderly (PACE)- Is available in certain states. You must be 55 year old & live in an area where PACE is offered. You must meet the requirements of needing skilled care. It is a benefit available under both Medicaid & Medicare that permits a patient to live at home and receive in home services as an alternative to being in a skilled nursing facility. It offers medical, social, rehabilitative, personal care, nutritional, meals, and counseling services. It is available 24 /7/ 365.

Medicaid Health Insurance - Is a state and federally government program that helps people with low incomes and limited assets. Who is eligible and what services are covered varies from state to state. It pays for some health services & nursing home care.

Medicare Ombudsman – Is a person who provides help to Medicare participants regarding insurance complaints, grievances, and requests for information. They can also help explain your Medicare options, rights, and protection.

Legal Services – It is a good idea to update your power of attorney, living will & estate, and have a health care proxy in the state where you reside. If you already have these legal documents, it is a good idea to review them every few years to make sure there are no changes in your wishes.

Second Medical Opinions – Most insurance will provide coverage for an office visit in connection with a second medical opinion for a cancer diagnosis, recurrence, or treatment options.

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Commercial Insurance

Insurance Carriers in the USA include BSBS, Aetna, United Health Care. Because each insurance company has different policies, it is a good idea to check with your carrier to find out the specific details of your coverage. Be sure to ask what your policy covers for labs, x- rays, medications, and diagnostic testing.

  • If you do not have insurance, ask to speak to your hospital’s (or center’s) financial advisor to discuss options with you.
  • Other Commercial Insurance resources are to contact your Employee Benefit Representative or Human Resources Department with your employer.
  • Also ask if your Insurance Plan provides coverage for a Medical Case Manager who can help answer questions and make referrals to other community resources that could help you.
  • Many insurance plans require you select a Primary Care Physician (PCP). Choosing your PCP is important. All in- network care except for emergency & certain other services must be provided, arranged, or authorized by your PCP. Many plans require the PCP to make a referral to see a specialist. Your insurance company will send you a letter confirming the referral.
  • You will receive the highest level of coverage when you receive in- network benefits. If you choose to see a specialist who does not participate with your insurance plan or who is outside the network, you will have to pay higher costs. You will also pay higher costs if you do not have the appropriate referral or authorization.
  • Having a referral doesn’t necessarily mean a service is covered. Your insurance company will only pay for services that are part of your health plan as defined in your contract. Also if a service is subject to a benefit limit (# of visits per year), they will not cover services in access of that limit

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Understanding Medical & Legal Coverage


EC Knowledge – Check List

  • To Do List (review your contract as to what is covered; speak to your hospital’s financial representative, medical case managers/community resources)
  • In-patient hospitalization, *skilled nursing, *assisted living, *home health care, *prescription drug coverage, *hospice coverage.
  • What is a Medicare ombudsman?
  • Medical Assistance
  • Program All Inclusive for Elderly (PACE) – at home services as an alternative to skilled nursing care.
  • Commercial Insurance – Work with your employer / Human Resources Dept.
  • What is a PCP?
  • Referrals / pre- authorizations
  • In-network vs. out of network benefits.
  • Tips on how to Resolve issues with my insurance company
  • What’s covered (hospice, palliative care)

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Legal Planning

  • Visit your attorney to make sure you have an up to date will & estate, arrange guardianship for any under age children, POA, health care proxy.

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Author: Former ECAA Board Member, Michele Reiland
Last updated: January 3, 2014 at 11:48 am

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